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Urology

Urology


WHAT IS UROLOGY?

Urology is a science that examines and treats male and female urinary tract diseases (kidney, ureter, bladder, prostate, urethra) and male sexual and fertility diseases (testes, penis, infertility or sexual problems).

Biruni University Hospital provides service with its experienced and academic staff for all examination and treatment procedures of urological diseases groups.

The treatment of urological diseases requires the use of new and innovative technology in interventional procedures as well as the knowledge and unit of the physician. In our hospital, minimally invasive urological surgeries that require technology and experience are performed endoscopically and laparoscopically. Endoscopic treatment of prostate and stone diseases is performed using holmium laser and plasmamakinetic. Varicocele surgery is performed by using microsurgery which is the gold standard in the world. Cancer operations are performed laparoscopically and endoscopically depending on the disease. All diagnostic methods (hormone assays, penile Doppler) and treatment (drug therapy, shock wave therapy, injection and surgery and penile prosthesis) are used for male sexual problems (erection, premature ejaculation).

 

UROLOGY ISSUES

  • Kidney and Urinary Tract Diseases
  • Bladder Diseases
  • Prostate Diseases
  • Diseases of Penis and Testes
  • Venereal Diseases in Men
  • Child Urology
  • Gynecological Urology
  • Endoscopic Urology
  • Impotence
  • Infertility in Men

 

DIAGNOSIS AND TREATMENT METHODS

  • Kidney Stone (ESWL – URS – RIRC) – Descriptive article
  • Bladder cancer
  • PSA-Prostate biopsy
  • Prostate cancer
  • Varicocele – Descriptive text
  • Prostate cancer

 

Bladder cancer

The bladder is a hollow organ in the lower abdomen where urine builds up. Bladder cancer is a disease in which malignant neoplasms occur in the mucous membrane or in the wall of the bladder. Bladder cancer is about 3 times more common in men. Smoking and chemical exposure are the main causes.

The cancer in the wall of the bladder can be superficial (cancer of the bladder that does not spread into the muscle) or can spread into the muscle of the bladder (Muscle invasive bladder cancer (MIBC)). MIBC is more likely to spread to other parts of the body.

 

Bladder Cancer Symptoms

Bladder cancer is most often marked by blood in urine (hematuria). Blood in the urine can be seen visually (macroscopically) or according to laboratory tests.

Other complaints:

  • Painful urination
  • Feel of the urination urge
  • Frequent urination
  • Particles in urine

Cystoscopy

While imaging methods (ultrasound, computed tomography) are used for the initial diagnosis of bladder cancer,  the gold standard for an accurate diagnosis is cystoscopy. This process, which allows a direct view of the urinary bladder from the urinary tract using a fiber optic camera, takes about 10 minutes, and the patient can go home that day. This technique, which has the same principle as the methods of endoscopy and colonoscopy, can be performed painlessly using sedation.

 

Transurethral Resection of Bladder Tumors

In the case of tumor formation / mass in the bladder, a closed resection (scraping of the tumor) can be performed immediately in the same or another session, depending on the request of the patient. In the case when bladder cancer is limited by the organ, both diagnostics, treatment, and the pathology elimination can be performed in one session using the TUR method (closed method for bladder surgery from the urethra). During TUR surgery, there are no cuts in the body, the patient goes home every other day, stays with a catheter for 1-2 days. The patient does not feel pain during or after the procedure and can return to his usual life within 3-4 days.

 

Research

After the initial TUR for diagnosis and treatment, cancer research is carried out using pathology and imaging methods. Tumors that do not penetrate the muscle are accompanied by periodic cystoscopy (examination of the bladder), regardless of the relapse of the tumor. If a relapse rate of more than 50% is considered for bladder cancer, these patients should be monitored for 5 years, regardless of their complaints. With high grade(Undifferentiate) or widespread tumors, BCG drug therapy is periodically injected into the bladder.

 

Cystectomy (removal of the bladder)

To treat muscle invasive bladder cancer, the bladder must be removed. The operation is performed with 15 cm incision in 4-5 hours. The patient stays in the hospital for an average of 6-7 days. After removing the bladder, a new urine bag is made from the intestine,  which connects to the patient’s abdominal cavity (ileum) or the urinary canal depending on the patient’s condition.  With a new bladder (neobladder),  patients may urinate normally after surgery. During the operation, the intra-abdominal lymph nodes are also cleansed, so that the cancer metastases are removed from other organs. Although postoperative urinary incontinence, or inability to urinate, urinary tract infections can occur, the patient can also spend his life completely normal. Chemotherapy may be required before or after surgery, depending on the stage of the cancer.

 

Prostate diseases

The prostate is the gland located under the bladder that surrounds the urinary tract that goes out of the bladder. The task of the prostate is to create a fluid that nourishes sperm. Inflammation of the prostate gland manifests itself in young men as “prostatitis”, and is accompanied by pain and difficulty urinating. At an older age, cases of benign growth (BPH) and prostate cancer are often observed. It is recommended that men over the age of 40 undergo a urological examination to check the prostate.

 

BPH – What is benign prostatic hyperplasia?

This is a benign enlargement of the prostate gland, which is observed in 80 percent of men, depending on age. As a man ages, the prostate gland also continues to grow with him, and subsequently begins to put pressure on the urinary canal, which becomes the reason for difficulty urinating. If, after 55 years, every second man has a prostate gland that exceeds its usual size, one in four experiences difficulty urinating due to a prostate gland that presses on the urethra. The risk of prostate enlargement in patients with a family history is 4 times greater.

What are the complaints about BPH?

– Difficulty urine flow at the beginning of urination

– Sluggish and thin stream of urine

– Dripping continues at the end of urination

– Intermittent urination

– The urge to urinate comes suddenly

– Feeling of incomplete emptying of the bladder

– Frequent nightly urges

The constant presence of urine in the bladder makes the bladder more sensitive over time and causes an increase in complaints. In addition, impaired urinary circulation in the bladder can lead to stone formation and infections (inflammations) that cause burning, pain, and bleeding in the urine. Tumors of the urinary tract, infections, stones, neurogenic bladder, and tumors of the urinary tract can also cause similar complaints and should be checked by a urologist.

 

When should BPH be treated?

Although prostate enlargement occurs in more than half of men, not every patient needs treatment. Men with mild to moderate complaints may be treated with medication, and men with moderate to severe complaints may require surgical treatment. Men with complaints of BPH with an increase of 30-60% can get better by taking medication.

The most disturbing complaint of men is nightly urination. In addition, with a decrease in the amount of urine and flow rate, the remaining urine in the bladder can increase the wall thickness of the bladder and damage the urinary tract, causing irreversible damage. For this reason, men with such complaints most often go for surgery.

 

Reasons that require surgery:

 

– Inadequate emptying of the bladder causing damage to the kidneys

– Inability to empty

– Urinary incontinence

– Stones in the bladder

– infection

– Blood in the urine (hematuria)

– Complaints of urination that affect the quality of life

 

Endoscopic (closed) BPH (Benign Enlargement of the Prostate Gland) Surgery:

Endoscopic surgery of the prostate is the fastest and most acute urinary problem caused by BPH. The operation of the TUR-prostate (using a natural cavity from the urinary canal and accessible in the prostate gland) is based on the principle of resection (curettage) of the inner part of the prostate gland, which obstructs the canal. It can be bipolar (only burning or cutting), which is the gold standard for unipolar surgery of the prostate, as well as bipolar (to control bleeding during cutting).

They will remain in the hospital for 1-2 days, and then will be discharged. The patient returns home immediately after urination. If the patient returns to his daily life shortly after leaving the hospital, a full recovery may take 3-4 weeks. The success rate of the operation is 90%. The percentage of urinary incontinence in a patient after surgery is 2%. Leakage of urine after surgery 50%.

 

TURis – TRANSURETHRAL RESECTION IN SALINE

In our center, the TURis bipolar plasmakinetic resection system for the treatment of benign prostatic hyperplasia, which is originated from Japanese technology, is used.

Plasma energy is a special technology, it provides the resection, vaporization and cauterization of the prostate adenoma tissue. Thanks to plasma energy, high heat energy is provided in the intervened tissue, while the surrounding tissues are protected from heat damage.

 

The advantages of the TURis system

  • Reduced risk of transurethral resection syndrome or Water intoxication through the use of saline irrigation fluid. The irrigation fluid used is Normal Saline and not Glycine which is 10 times more expensive.
  • Reduced perioperative blood loss (65% less)due to safe bipolar hemostasis
  • Much lower blood clot formation and occlusion
  • A shorter surgical procedure
  • An early discharge from the hospital.
  • Earlier catheter removal time
  • Reduced costs (associated with postoperative blood transfusion, healthcare-associated infection, length of hospital stay, postoperative irrigation and a patient return electrode).
  • The use of saline irrigation fluid is cheaper and more readily available than glycine.

TURis system: With this system, surgery can be performed in 3 different techniques recommended in European and American guides according to the needs of the patient. While resection (cutting) or vaporization is performed in small prostates (≤80-100 cc), bipolar enucleation (Bi-LEP) surgery may be preferred in larger prostates. Even patients who use blood thinners and who have intensive additional diseases can be operated safely with vaporization method.   The bleeding-free and safe nature of the method allows patients to go home within a day. In the Bi-LEP method, doctor can operate safely with the closed method in a large prostates, which used to be treated only with open surgery.

 

Prostate cancer

What is prostate cancer?

Prostate cancer is a malignant tumor of prostate tissue. The risk factors of cancer are age, family history and race. While one in six men is diagnosed with prostate cancer at some stage in their lives, 85% of local cancers are treatable. While 50% of prostate cancer deaths occur in men over 75 years of age, this rate can be reduced by 30% with psa screening.

 

Prostate cancer symptoms

85% of prostate cancers are diagnosed in the blood by PSA values ​​or physical examination without any complaints. In rare cases where there is a complaint;

 

  • Difficulty urinating or holding
  • Poor or intermittent voiding speed
  • Erection problems
  • Painful ejaculation
  • Blood in urine
  • Pain in the waist, hips and thighs

 

Prostate Cancer is Diagnosed Based on Prostate Biopsy Results

A prostate biopsy is performed in patients with a PSA> 4 ng / dl or if abnormal stiffness is felt during examination of the prostate gland. In principle, laboratory confirmation is performed by a PSA blood test at least twice before the biopsy. Clinical evaluation should ensure that the patient does not have acute prostatitis (febrile prostate) causing an increase in PSA levels.

Typically, a prostate biopsy is performed using transrectal ultrasound (TRUS BX). The prostate, as a rule, is systematically divided into 12 quadrants, and a piece is taken from each quadrant using a needle. A prostate biopsy can be done safely, as it does not cause cancer to spread. This procedure, which can also be performed under local anesthesia, can also be performed painlessly with mild sedation, if necessary. If necessary, a multiparametric MR-test of the prostate can be performed before the biopsy, and MR-fusion (combined) biopsy can be performed from the indicated parts.

Side effects that can be detected with a prostate biopsy

  • Blood in urine
  • Semen blood
  • Infection in the prostate or urinary tract
  • Blood from the anus

The likelihood of infection of the prostate during a biopsy of the prostate can be reduced by using appropriate antibiotics and cleansing the pelvic area. The probability of a severe infection is less than 1%.

After examining the result of a biopsy in pathology, the degree of cancer (Gleason’s degree) is just as important as the diagnosis of prostate cancer.

Cancers of the 6th grade of Gleason and below are considered low rank, 7th intermediate and above 8th attacking cancer. Treatment is selected in accordance with the pathological and clinical stage, skipping of the bone and lymph node.

 

Prostate Cancer Treatment

With early diagnosis of prostate cancer, the likelihood of treatment and life without cancer increases. The vast majority of cancers (85%) detected in the early stages are cured with proper treatment, and the cancer does not recur within the first 5 years. After the fifth year, the PSA value, which indicates cancer in 20% of patients, may increase again. Treatment options depending on the level of cancer: active observation, surgical treatment and radiation therapy.

 

Nerve-Saving Robotic Prostatectomy

For patients with clinically localized prostate cancer, surgical treatment is based on the principle of complete removal of the prostate gland by preserving as much of the surrounding nerve structures as possible, responsible for penile erection and subsequent bladder and canal connection. One of the most important advantages of the operation is that the lymph nodes in the abdominal cavity and the cancer that has been distributed across all the cells can also be cleaned. Thus, it is possible to treat patients with moderate and progressive form of prostate cancer and increase their life expectancy.

This operation, which takes approximately 2-3 hours, is performed with a small incision of approximately 10 cm under the navel. Patients who remain in the hospital for 3-4 days remain under observation for 10-14 days after surgery. On the first day after surgery, patients can get up and walk. The expected return of the patient to normal life is 3-4 weeks. With today’s method, severe bleeding and urinary incontinence are rarely observed (10%), and in many patients an erection can persist. Urinary incontinence is observed in the first 3 months with coughing and sneezing, and 90% of urinary incontinence disappears at the end of the first year. In some patients, erection improves during the first year after surgery (50%), in the remaining group of patients additional supplements may be required.

 

What is a varicocele?

Varicocele is an abnormal expansion of the veins of the testicle in the scrotum. Usually, when the valve mechanism, which prevents the leakage of blood in the veins, which collects blood back into the heart, is destroyed by gravity, blood is deposited in the scrotum, causing a varicocele. Blood accumulated in the scrotum disrupts the production of sperm and testosterone with increasing temperature and harmful metabolites. In approximately 15-20% of men, varicocele is detected during the examination.   80% of varicocele is more often in the left ovary, 15% is bilateral.

 

How does varicocele affect men?

The three main problems caused by varicocele are impaired fertility (inability of having children), decreased testosterone production in the testicle, and scrotal discomfort. 20% of men with varicocele experience a decrease in sperm count, speed or quality and as a result, difficulty in having children. The group of patients in which varicocele affects fertility most are men who are older than thirty, who have children before and who have problems with the second or third child. Although testosterone drop does not affect most men clinically, excessive testosterone drop in some men can cause metabolic syndrome, diabetes and osteoporosis.

 

What are the symptoms of varicocele?

  • Inability of having children
  • Scrotum pain
  • Low testosterone
  • Swelling / vascularization in eggs

Varicocele and pain

Varicocele pain is especially seen in men who stand for a long time or do physical activity. The pain is usually mild or moderate and decreases with lying down and raising feet. Surgery may be considered in men with typical varicocele pain, but the pain may not go away after surgery. Microsurgical spermatic cord denervation (nerve ligation) can be performed in patients with excessive pain.

 

Varicocele and fertility

Varicocele is detected in the examination of one of every 3 men who cannot have children. Varicocele can impair the number, speed, and shape of sperm, making it difficult to have children, as well as increase the risk of miscarriage by affecting sperm DNA. If the varicocele is causing a decrease in testicular volume or impaired sperm quality, it should be treated with microscopic surgery.

 

Varicocele microsurgery

Because of the lowest postoperative recurrence and complication rate, the gold standard treatment method in varicocele surgery is microsurgery. Under general / spinal anesthesia, after 4-5 cm, an incision in the groin opens up access to the seminal nucleus, under a microscope with an increase of 8-10 times, without touching the arteries and lymph nodes, the swollen veins are connected. Since a microscope is used during surgery, the risk of testicular contraction or re-development of hydrocele after surgery is minimal. And since there is no muscle incision due to the subinguinal incision, the possibility of hernia development and pain after surgery is extremely low. With this minimally invasive approach, the patient can return home the day after surgery, quickly return to his daily life. For the success of the treatment, the operation should be carried out by a person skilled in micro-surgery.

 

The success of microvaricocelectomy

 

– More than half of patients have an increase in sperm count above 50%

 

During the year, spontaneous pregnancy is provided in a third of patients, the likelihood of pregnancy increases by 2.2 times.

IUI (vaccination) is sufficient for a third of patients who require IVF / ICSI

Testosterone (male hormone increases) after surgery

Kidney stone treatment

 

ESWL (stone breaking by shock wave)

ESWL, which is not an interventional procedure, is suitable for the destruction of small kidney stones visible on x-rays. Stones in the kidneys or urinary tract are broken by a sound wave. This method should not be used to treat pregnant women, those who use blood thinners or those who have problems with blood coagulation, those who have chronic kidney infections, or those who have a ureteral stricture. This operation is also not suitable for patients who require complete or rapid cleansing of kidney stones.

 

Ureterrenoscopy (URS)

 

This is the process of reaching stones in the urinary tract endoscopically (without any incision, by penetrating the urinary tract using a camera) and separating them using laser cutting. After the procedure, a temporary catheter is inserted and the kidney is easily emptied. The patient leaves home on the same day or every other day. With URS, stone can be reached anywhere in the ureter and kidney. While stiff URSs are preferred for stones in the ureter, kidney stones are achieved using flexible URSs (RIRS). URS operation is preferred, especially during pregnancy, using blood thinners, obesity, complete and quick stone cleaning. In our center, all closed endoscopic surgeries are performed using a rigid and flexible URS and a holmium laser.

Percutaneous nephrolithotomy

This is a form of endoscopic surgery that is used to clean stones larger than 2-3 cm in the kidneys and eliminates the need for open  surgery on kidnes. The kidney is reached with a small incision at a distance of 1-2 cm from the patient’s waist with the camera, and large stones are cleaned quickly and accurately. Although the surgical procedure takes about 3 hours, the estimated hospital stay is 2-3 days. In our center, a mini-percutaneous (performed using small cameras) method is also used for pediatric patients and patients who needs a minimally invasive approach.

 

Erection problem

The problem with an erection is that the inability to initiate or maintain an erection necessary for intercourse is constant or recurring. This problem can occur due to the effects of lifestyle and drugs, as well as problems that occur in blood vessels that carry the blood needed to harden the penis.

 

Who has erection problems?

  • Men over 40
  • Diabetes (diabetes) patients
  • Patients with prostate cancer surgery
  • Cardiovascular patients
  • Cholesterol and patients with high blood pressure
  • Depending on the side effects of certain drugs
  • Those who are overweight
  • Alcohol and cigarette smokers
  • With psychological problems

 

Shock Wave Treatment with LI-ESWT

LI-ESWT is a newly developed treatment for erection problems seen in approximately 69 percent of men over 40. In the treatment of low-energy acoustic shock waves (LI-ESWT), which do not cause the patient any discomfort, are used with specially designed caps for this treatment.

Scientific studies have shown that shock waves cause the formation of new cells, restore the internal structure of the vessel and form new microvessels (neonendothelialization and angiogenesis), thereby increasing blood supply to the penis and solving the problem of vascular erection. The device is an important system designed exclusively for the treatment of erectile dysfunction and without systemic side effects. LI-ESWT shock wave therapy; This provides an improvement in vascular erectile dysfunction, providing the formation of new vessels in the penis using low-intensity sound waves.

 

How is this applied and how long will it take?

Shock wave therapy, which is used during 20-minute sessions, 6-12 sessions in lung patients and 12-18 sessions in severe patients, stimulates the production of new cells and causes the restoration and formation of new vessels in the vessels of the penis. Thus, shock wave therapy creates the possibility of long-term treatment by correcting insufficient blood supply, which is one of the main causes of erection problems. Shock wave therapy, which has been successfully used in coronary heart disease over the past 15 years, has also been successful in erectile dysfunction using LI-ESWT technology. Due to local application to the penis, LI-ESWT treatment does not have any side effects on any other organs, including the cardiovascular system, and there is no pain or pain during the procedure.

Shock wave therapy does not interact with the drugs used. The patient does not require any preparation and restrictions before and after treatment. Treatment does not require any sedatives or anesthesia. The patient can continue his daily life after the procedure. There is no hospitalization. With shock wave therapy, in the case of erectile dysfunction, the obligation to use medications and medication-related side effects disappear. It also eliminates the need to plan ahead for the necessary sexual intercourse when using the medication.